Background: Successful first-pass endotracheal intubation is the desired outcome of all ER physicians as this can stave off hypoxemia and aspiration. The bougie is one tool we have in our armamentarium that may be able to help with intubation. Many providers use this device as a rescue device after a failed attempt at intubation, instead of as a primary device in intubation. This study sought to investigate the use of the bougie as a primary intubation device (Bougie 1st Intubation) in the ED instead of as a backup or adjunct in the ED.

What They Did:

Retrospective, observational study

Determine the association between bougie use and first-pass intubation success

Strengths:

Automated software combined video camera footage with, the patients vital signs, as well as audio recordings of the room for more accurate evaluation of endpoints

First pass success was discretely defined

This study asks a clinically important question

Missing data was left blank with no assumed value which would neither over- or under represent endpoints

10% of videos were evaluated by a second reviewer to ensure interobserver agreement

Reviewers were blinded to study aims

Adjusted for variables that could confound the relationship between bougie use and intubation success

Limitations:

Single institution with frequent bougie use and familiarity with the device may limit generalizability to other institutions

Retrospective design subject to bias

Pre-intubation assessments (ie. Mallampati) were not collected. These can influence first-pass success

Hypoxemia data could not be obtained from 181 videos (21% of cases), as median duration of intubation was longer with the use of bougie, this would be an important adverse outcome that would need to be monitored

Adverse events such as upper airway trauma, tracheobronchial injury, or pneumothorax were not recorded in this study

Discussion:

It would have been nice to see if bougie makes a difference on all airways, simple airways, or more difficult airways where visualization is limited

Also it is important to remember that a rescue device is only useful if you are comfortable with it, so using it in frequent intubations makes sense, however it is unclear that using it in every intubation is necessary

Author Conclusion: “Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.”

Clinical Take Home Point: This is the largest trial to date on the use of bougie 1st intubation and first-pass success. However, this study will not change my practice of using a bougie on every intubation. Further prospective, multicenter RCTs taking into account the costs, adverse events, and pre-intubation assessment of airway difficulty are still needed before changing global practice